Combat Trauma Innovations
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This briefing from the Air Force Medical Service is directly applicable to civilian and military communities who need to be prepared for managing medical trauma scenarios. This presentation focuses on integrated trauma management systems.
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Combat Trauma Innovations
- 1. Unclassified Continuous Learning In An Integrated Trauma Management System Lt Gen C. Bruce Green Surgeon General USAF 18 Jan 2011 Combat Trauma Innovation Unclassified
- 2. Global Vigilance Persistent, Actionable Global Reach Anywhere, Anytime Global Power Rapid, Decisive Air Force Mission Fly, Fight, and Win…in Air, Space, & Cyberspace With Precision and Reliability as Part of the Joint Team
- 3. Lakenheath RAF Croughton Mildenhall Ramstein Landstuhl Pirmesens Spangdahlem Scope Of Air Force Medical Operations McChord AFB Kadena Yokota Misawa Fairchild AFB Malmstrom AFB Minot AFB Lajes Grand Forks AFB Asbgabat Pristina Manas Incirlik Hanscom AFB Mountain Home AFB Bagram Kandahar Kabul Khost Ellsworth AFB Osan Kunsan Beale AFB Aviano Kuwait McGuire AFB FE Warren AFB Qatar Hill AFB Travis AFB OIF/OEF Dover AFB Manas KYRGYZTAN Offutt AFB Eskan Village Andersen Wright Patterson AFB Buckley AFB Andrews AFB Honduras Djibouti USAF Academy Bolling AFB Bagram Curacaco Monrovia Jolo IRAQ Whiteman AFB Kirkuk Vandenberg AFB Peterson AFB Nellis AFB Scott AFB Langley AFB Balad McConnell AFB AFGHANISTAN Baghdad Ali Base Bogota Edwards AFB MantaCity Seymour Johnson AFB Ali Al Salem KUWAIT Vance AFB Los Angeles AFB Kirtland AFB Pope AFB Luke AFB Tinker AFB Shaw AFB Little Rock AFB Cannon AFB Altus AFB Al Dhafra, UAE Davis-Monthan AFB Columbus AFB Charleston AFB Sheppard AFB Robins AFB Holloman AFB Dyess AFB Barksdale AFB Maxwell AFB Goodfellow AFB Moody AFB Eglin AFB 42,000 Medical Personnel 63 Facilities in 34 States, DC, And Guam 12 Medical Treatment Facilities In 7 Countries 1,707 AF Medics Deployed In 19 Countries In 53 Different Locations Eielson AFB Keesler AFB Tyndall AFB Elmendorf AFB Hurlburt Field AFB Laughlin AFB Patrick AFB Hickam AFB Randolph AFB Lackland AFB MacDill AFB
- 4. Joint Medics Are Key to Success …at Home and Deployed Fostering a Spirit of Teamwork and Integration to Deliver Trusted Care HOME STATION GLOBAL OPERATIONS Readiness is Job # 1 We exist to deploy clinically current medics and keep AF personnel deployable for global operations Delivering Home Station Healthcare Underpins Readiness Peacetime care sustains clinical skills and continuity to do Job #1
- 5. Ready…For Anything! Afghan patient is brought to Bagram ER with head trauma Stat X-rays are ordered This is what they found… Craig Joint Theater Hospital Bagram AB 14.5mm Explosive Round UXO OR team dons flak vests Non-essential personnel evacuated Second surgical suite managing patient with internal bleeding unable to stop…presses on Surgical Team successfully removes UXO Service Before Self…Just Another Day In The AOR!
- 7. Facilities
- 8. Manpower
- 9. Equipment
- 13. Local, Higher Level of Medical Care
- 16. Triage capacity
- 17. Contamination (?)Comprehensive Approach To “Manage The Flow Of Patients”
- 18. Scenario DeterminesForce Package and STEP Rate Mt Pinatubo, PI (1991) Balad AB, Iraq Houston, TX (2001) Humanitarian Mission Triage Delayed/Minimal patients Support to Civil Authorities Mission Triage Delayed/minimal patients Relieve burden on local medical infrastructure Military Mission Full spectrum care Modularity Leverages Maximum Capability & Response
- 19. Transformation Of OurAir Expeditionary Force Unpredictability of scale/scope/location of future crisis Optimized resources…based on capabilities vs. population at risk Requirement for light, modular & rapid response Air Evacuation “Unique Assets” In-flight ICU Capabilities Manpower Packages “Portable Hospitals” Equipment Packages Mobile Aeromedical Staging Facilities Humanitarian Assistance Rapid Response Team Sustainment Packages “Care in the Air” Positioned, Ready, and Strategically Linked for Global Response
- 20. Aeromedical Evacuation: The Lifeline Home Ramstein EUCOM Andrews Travis Scott CENTCOM Kadena PACOM Hickam C-17 Transport Aircraft Air Ambulance Configuration Empty Cargo Hold Airborne ICU Capability Continuing or increasing levels of care… from point of injury to resuscitation to definitive care! 9
- 21. En Route Continuum Of Care Time from “battlefield” to combat surgical intervention: Currently: 20-75 minutes Time from “battlefield” to Landstuhl Regional Medical Center, GE: Currently: 24-48 hrs Time from “battlefield” to CONUS MTF: Vietnam: 45 days First months of OEF: 8 days Currently: 2-4 days Integrated “Joint/Combined/Coalition” System of Systems
- 22. Advances in Aeromedical Evacuation + Casualty Care 1918 JN-4H C-54M WW II 30% 1942 Korea 25% 1950 C-47 Vietnam 24% C-131A 1968 Persian Gulf 24% 1990 C-9 Combat Mortality Rate OIF/OEF <10% 2010 C-17 11
- 23. Lessons Learned From Operational Missions Operation ENDURING FREEDOM IRAQI FREEDOM Earthquake Indonesia 2010 2000 1990 Houston Flood Hurricane Katrina Earthquakes Chile Earthquakes Haiti Health Response Team (HRT) Primary Requirement: “Care Upon Arrival” 1st Patient in 1 Hour 1st Surgery in 3 Hours Airlift/Deployment Requirements: Rapid Response MedicalCapabilities: Emergency, Resuscitative, & Surgical Care < 24 HRS + Raising The Bar Through Adaptive Planning And Innovation
- 24. Transformation in Action: EMEDS-Health Response Team (HRT) 13 Emergent care: 30 min ER : 2 hours OR: 4 hours FOC: 12-18 hours Expeditionary Medical System HEALTH RESPONSE TEAM 5 Tents 3K sq ft The Future of Expeditionary Operations…NOW!
- 25. 14 What is the Joint Theater Trauma Registry (JTTR)? Data feeds into Joint Theater Trauma System (JTTS) Largest combat Injury database in existence Compilation of identified information taken from the medical record, expert clinical inference, scoring and coding schematics, probability determination and performance improvement data requiring human intervention Currently represents >24,000 US trauma patients, >53,000 total patients, >90,000 total patient-records Right Patient, Right Time, Right Place, Right Care
- 26. Joint Theater Trauma System Clinical Practice Guidelines 15 Examples: #4 Amputation #9 Compartment Syndrome #22 Pelvic Fracture Care #24 Prevention of DVTs #25 Spine Injury Surgical Mgmt #31 Vascular Injury Translating Lessons Learned into 31 Evidence-Based CPGs & counting… http://www.usaisr.amedd.army.mil/cpgs.html
- 27. Lessons Learned:Translating Experiences Into Practice Authors: Marla J. De Jong Richard Benner Patricia Benner Maggie L. Richard Deborah J. Kenney Patricia Kelley Mona Bingham Annette Tyree Debisette RESEARCH Mass Casualty Care in an Expeditionary Environment: Developing Local Knowledge and Expertise in Context January-March 2010 Journal of Trauma Nursing – Volume 17, Number 1 Success depends upon transfer of experiential learning Teamwork, communication, & tracking during mass casualties is critical Common Practice simplified the complex and improved flow/efficiency Know your people, know their skills, and utilize them appropriately Maintain situational awareness and keep the “big picture” in focus If team members practice at maximum scope of care…we saved lives! Talk to each other/help team cope with exposure to constant trauma A
- 28. Integrating Our Lessons Learned Into Operational Practice 17 Training Tactics 1st Responders Combat Medics Navy Corpsman Self-Aid Buddy Care Mobile Forward Surgical Teams Critical Care Air Transport Teams Technology Tourniquets + Body Armor + Adv Bandages Procedures Vascular Shunts Wound Vac Blood Products Refining Operations & Integrating Technology To Save Lives!
- 29. 18 Scope Of Vascular Injury Rates of Vascular Injury in Modern Combat 12%* 13% 9% *Rate of vascular injury 5 times previously reported in war Data From: GWOT Vascular Initiative
- 30. 19 Patient-Based Outcomes Study Clinical benefit from early restoration of flow with temporary vascular shunts (TVS) in follow-up years
- 31. Intra-Theater Critical Care Transport Gap GOAL: Maintain Equal or Greater Level of Care During Intra/Inter-Theater Patient Movements En Route Critical Care Transport Gap Definitive Care Level of Care Lvl-III/CSH, EMEDS, EMF Theater Hospitals Lvl-II/Forward Surgical Teams Damage Control Surgery & Resuscitation BAS ATLS/ACLS WoundedTCCC, SABC Continuous Increase inLevel of Care Provided Time
- 32. Tactical Critical Care Transport Team (TCCTT) Refining Operations & Integrating Technology To Save Lives!
- 33. When The War Is Over… US Level I Trauma Centers 5K evaluations Per 2,000,000 population Joint Theater Trauma System 8K evaluations per 200,000 population vs. 16x greater Incidence rate How Do We Prepare For The Future? 22
- 37. Increasing to 241 enrolled students in FY10
- 39. Goal of 50 graduates/yrBuilding the Foundation To Sustain the AFMS!
- 41. W-P/Miami Valley
- 42. Luke/Scottsdale HC & Maricopa County
- 43. Nellis/Univ. MC
- 44. Trauma & Surgical Skills (Baltimore)
- 46. Trauma Skills (St. Louis)Keeping Medics Ready Through Civilian Partnerships & Programs 24
- 47. Modernization:Current & Future Innovations Current Innovations Future Innovations Tricorder Laser Detector Development Mobile Oxygen Storage Tank (MOST) - Testing with NASA Force Health Protection Next Generation Spinal Immobilization Device Fielded 42 units - Jun 09 Air Force Trauma, Resuscitation & Stabilization Acoustic Stethoscope Positioned for Joint Use IOC: FY11 Expeditionary Medicine Compartment Syndrome Detection System Video Assisted Intubation Device (VAID) IOC: FY11 Enroute Care Enroute Care Taking Ideas From Concepts To Reality!
- 48. Medical InnovationsUnder Development Revolutionizing Prosthetics Program Blood Pharming Endless O+ supply DoD + Univ. of Pittsburgh Bone Cement Project
- 49. Shaping the Futureof Military Healthcare Patient-Centered Care Synergy- Joint & Coalition Organizational Agility Precision Healthcare Technology Integration AFMS Imperatives Provide The Framework For The Future
- 50. Whatever It Takes!Teamwork, Technology, & Determination UK Aeromedical Evacuation Control Center (AECC) Birmingham Military Hospital Afghanistan (OEF) Camp Bastion Regensburg University Hospital Ramstein AB British soldier Suffers gunshot wound and loses right lung 1st AE of traumatic pneumonectomy on German-made Novalung bypass Landstuhl Lung Rescue Team (Army-AF) Conducts 38-hour mission, goes through 200 pints of blood 1000+ Professionals With One Goal Working Together…”It’s Magical”
Notas del editor
- Continuous Learning in an Integrated Trauma Management System - Continuity of Care from Point of Injury to Home Station Care - Integrating Lessons Learned During Ongoing Combat Operations - Leveraging Innovations and Informatics To Improve Survivability
- Over 85K pts evacuated from CENTCOM as of 17 Dec 2010
- Flood: Houston Oct 1994OEF/OIF: Oct 2001Hurricane: Katrina Aug 2005Earthquake: Indonesia Oct 2009Earthquake: Haiti Jan 2010Earthquake: Chile Feb 2010Further notes: -EMED HRT (Healthcare Response Team) is a medical only package
- Set to play automatically (no need to click) clip runs ~ 35 seconds
- It is NOT the medical record, a research database, although it supports it, or a patient tracking tool
- Prosthetic Limbs That Match the Real ThingIt wasn't until 2000 that the Pentagon started investing in better prosthetics. In only a decade, military-funded research has transformed artificial limbs, which had remained largely unchanged since the 1940s, into devices that increasingly resemble real limbs.And soon, prosthetics might be nearly indistinguishable from the appendages they replace. Earlier this year, Darpa launched the latest phase of it's Revolutionizing Prosthetics Program: This time, the agency is after devices that fuse severed nerves with robotic limbs — yielding prosthetics that offer robust freedom of movement and can acutely distinguish between myriad sensations.Photo: U.S. ArmyType-O Blood, in Endless SupplyUntil troops can hibernate through their injuries, the military will rely on stockpiles of donated blood. But already, they're making quick strides toward replacing human donation with megadoses of lab-grown universal-donor units.Under Darpa's Blood Pharming program, biotech firm Arteriocyte has already shipped off its first batch of type-O red blood cells — derived from umbilical cord-blood units — to the FDA. And with critical blood shortages threatening hospitals nationwide, the project would have lifesaving civilian applications.Bone Cement ProjectSome of the most debilitating war injuries, from lost limbs to mangled muscle tissue to permanent burn scars, could soon benefit from cutting-edge regenerative procedures.Human clinical trials of the latest in extreme regenerative medicine — including bone-fusing cement and muscle-growing cell scaffolds — are being fast-tracked, thanks to an extra $12 million in funding from the Department of Defense.Researchers at the University of Pittsburgh are working on some of the most promising Pentagon-backed medical research projects. Just last month, Joint Chiefs of Staff Chairman Admiral Mike Mullen visited the university’s labs to see the science firsthand. And despite the looming threat of a shrinking Pentagon budget, he told them that “10 years doesn’t satisfy any of us,” where clinical trials were concerned.And that’s exactly what this funding infusion is going to address. Dr. B.J. Costello, the lead researcher behind the university’s bone cement project, told Danger Room that the Pentagon’s contract is meant “to catapult us forward.” Costello’s program was expected to be in human clinical trials in 5-7 years. With the new grant, it’ll be more like 12 months to 2 years.“We needed more help with the process of FDA approval and associated expenses, which a company would pay for if they were planning to produce and market this science,” he said. “Instead, the Department of Defense is picking up that slack.”Costello, whose program involves the creation of an injectable compound designed to repair cranio facial bone damage or spur normal bone growth, expects to start trials on 20 patients, most of them veterans, within a year. If those trials go well, they’ll expand to test more people or explore using the cement for different, more serious procedures.“Right now, we’re looking at mild to moderate injuries,” he said. “But eventually this could treat long bone injuries, or have civilian applications.”And those applications would be widespread. The bone cement could replace metal plates, repair bone damage from car accidents or assaults, and even regrow entire portions of a human skull.Costello’s hoping the grant will also help them move forward on manufacturing facilities, where the product can be mass produced in a sterile environment.The Pentagon grant will also hasten clinical trials for muscle tissue regeneration and a novel method of treating burn injuries. Costello is confident that all three procedures are ready for human use.“The Department of Defense did their homework, and these projects are the cream of the crop,” he said. “This isn’t pie-in-the-sky research. We’re ready to roll.”[Photo: Noah Shachtman]See Also:http://www.wired.com/dangerroom/2010/11/military-medical-projects/?pid=112
- Shaping the Future of Military HealthcareDefinition of an "imperative": a philosophical concept that implies an obligation. For example, we have an obligation to deliver patient centered healthcare under a medical home construct or strategy via FHI as a key means. An imperative is and how we will support our priorities and shape our approach to our mission.Specifically, to assure success today and tomorrow, we are focused on the following theme:Patient-Centered Care: Patients want someone who cares with reliable and universally accessible information that allows active participation in their health care.Technology Integration: Our AFMS must continually monitor all (not just medical) technologies; understand how they will influence our AFMS mission, and rapidly integrate them.Synergy-Integration – Joint, Coalition, and Interagency: We must build partnerships and interoperability to advance cradle to grave health delivery. Precision Healthcare: We must minimize the cycle time from implementation of evidence-based medicine to common practice, and create incentives for prevention. Organizational Agility – Light, Lean, and Life Saving Capabilities: An organization that is able to respond, adapt, and influence changing environments quickly through agile processes as seen by changing approaches to acquisitions, facilities, technology; changing approaches to programming process, policy, and law. Process to adapt to changes, influence, changes, funding processes within the fiscal year, to respond between POM cycles.
- Additionally, Capt Solghan and his team successfully coordinated with the United Kingdom (UK) Aeromedical Evacuation Control Center (AECC) for the transport of a UK solider that suffered a blast injury that left him with only one functioning lung. Capitalizing on the capabilities of the USAF Lung Team stationed at Ramstein Air Base, Germany, and the technology of a Nova artificial lung, this UK service member was transported in the U.S. Aeromedical Evacuation System to Germany for critical treatment, and then finally to the Birmingham Military Hospital, UK, where he is now doing well. This success story demonstrated a multinational effort of over 1,000 aircrew, ground, and medical personnel.Army Maj. (Dr.) Eric Osborn, the pulmonary critical team leader, recalls a recent mission to treat a British soldier wounded in Afghanistan as team member Air Force Maj. Shannon Womble, assistant head nurse of ICU, looks on Monday at Landstuhl Regional Medical Center.Experimental lung device kept wounded British soldier alive By Mark Abramson, Stars and StripesEuropean edition, Thursday, August 20, 2009Photo courtesy of Landstuhl Regional Medical CenterThe Novalung works by filtering carbon dioxide out of a patient's blood and infusing oxygen into the blood. Ben Bloker / S&SArmy Maj. (Dr.) Eric Osborn, the pulmonary critical team leader, recalls a recent mission to treat a British soldier wounded in Afghanistan as team member Air Force Maj. Shannon Womble, assistant head nurse of ICU, looks on Monday at Landstuhl Regional Medical Center. LANDSTUHL, Germany — A team of doctors and nurses from Landstuhl Regional Medical Center used a revolutionary device during a recent medevac mission to save the life of a British soldier wounded in Afghanistan.The 19-year-old soldier, whose name was not released, lost his right lung and suffered a damaged liver when he was shot July 25 near Camp Bastion, a British base in Helmand province. Within hours of getting the call, the LRMC Lung Rescue Team was bound for Afghanistan.It took more than 200 pints of blood — and the use of a German-made device called the Novalung — to keep the soldier alive.The Novalung works like a temporary lung by filtering out carbon dioxide from a patient’s blood and oxygenating it. To use the device, a physician reroutes blood flow from a patient’s major vessels through the box by tapping the femoral artery and vein in the upper thighs. As blood flows from one leg into the box, it passes through a filter that leeches off the carbon dioxide and infuses the cells with oxygen, mimicking the trade-off that should take place in the lungs. The blood then goes back into the system through the other leg, refreshed.Last month’s flight was the first time the Novalung was used while transporting a patient.“Up until now, it’s never been used to move a patient,” said Air Force Dr. (Lt. Col.) Raymond Fang, LRMC’s trauma director.“He probably would have died [without the Novalung],” said Army Dr. (Maj.) Erik Osborn, the pulmonary critical team leader for the 38-hour mission.The Novalung is unlike other equipment or treatment used by the Lung Rescue Team because it has not yet been approved by the U.S. Food and Drug Administration. Each time the team uses the device, it has to report it to the FDA.Novalung is in the process of getting FDA approval.“We are preparing for clinical trials to get it approved in the United States,” said Nicholas Strout, Novalung’s global vice president of sales and marketing. “It will confirm that this is safe and effective. The trials will probably start early next year and could take six to 12 months.”Strout said he was on his way to the U.S. on Wednesday to meet with a company that conducts clinical trials. Novalungs have been used more than 5,000 times safely, he said.Doctors at the university hospital in Regensberg developed the Novalung, and the wounded British soldier was flown there after arriving at Ramstein Air Base. He remained hospitalized there on Wednesday, where his condition was listed as seriously injured, LRMC spokeswoman Marie Shaw said.No plans have been made to move him to Landstuhl or to a British hospital, she said.Landstuhl officials said the British Ministry of Defence wouldn’t authorize them to release the soldier’s name and details of how he got shot. Situations such as the treatment of the British soldier are why the team was started in November 2005 by Dr. (Col.) Warren Dorlac, the hospital’s intensive care unit director at the time, and his wife, Dr. (Col.) Gina Dorlac, a former medical director for the critical care air transport team at Landstuhl, Fang said. It’s also the reason the team got the Novalung. No one else in the Department of Defense has it, Fang said. “This patient sounded like he needed the lung,” he said. “It’s a pretty remarkable device.”